Stewardship / Resistance Scan for May 07, 2020

IDSA sepsis recommendations
Rapid ID, susceptibility test

IDSA urges changes to national sepsis care measures

The Infectious Diseases Society of America (IDSA) and five other medical organizations are urging changes to a national set of care measures for sepsis patients, with the aim of reducing unnecessary antibiotic use in patients who may not need them.

In a paper published yesterday in Clinical Infectious Disease, members of the IDSA Sepsis Task Force argued that the Centers for Medicare and Medicaid Services' (CMS's) Severe Sepsis and Septic Shock Early Management Bundle (SEP-1), which was implemented in 2015, has the potential to drive antibiotic overuse because it does not account for the high rate of sepsis overdiagnosis and encourages aggressive antibiotics for all patients with possible sepsis, regardless of the certainty of diagnosis or severity of illness. Of particular concern is that SEP-1 stipulates the same time-to-antibiotic goal for both sepsis and septic shock, even though the association between time-to-antibiotics and mortality is much stronger for septic shock than for sepsis without shock.

"IDSA believes the perception that any delays in antibiotic therapy lead to worse outcomes for patients with sepsis, regardless of the severity of illness, contributes to inappropriate antibiotic prescribing and is the wrong message to communicate to providers," the authors wrote.

Among the recommendations outlined in the paper is removing sepsis without shock from SEP-1 to mitigate the risk of inappropriate antibiotics for patients with signs and symptoms resembling sepsis but with a low likelihood of infection. The recommendations also urge that SEP-1 continue to focus on obtaining blood cultures before giving antibiotics, versus after, and that antibiotics be administered within 1 hour of septic shock being recognized. But they call for the criteria for septic shock to be simplified.

In an editorial, authors from CMS, the University of California, San Francisco School of Medicine, and Wayne State University say the IDSA has not met the burden of proof to establish that SEP-1 has increased unnecessary antibiotic usage, or shown that delaying antibiotics in patients with severe sepsis is safe.

"We are open to considering alternative antibiotic measurement strategies in severe sepsis and septic shock, but we cannot support a strategy of leaving severe sepsis patients without timely and appropriate antibiotic coverage," the authors wrote. CMS requires hospitals to publicly report their compliance with SEP-1 in order to receive additional payments.
May 6 Clin Infect Dis paper
May 6 Clin Infect Dis editorial


Randomized trial shows stewardship benefits of rapid ID, susceptibility test

In another study published yesterday in Clinical Infectious Diseases, the results of a randomized controlled trial found that use of a rapid organism identification and phenotypic antibiotic susceptibility test (AST) led to faster changes in antibiotic therapy in patients with gram-negative bloodstream infections (BSIs) when compared with conventional testing.

In the prospective trial, US researchers randomized 500 patients who had a positive blood culture showing gram-negative bacteria at two US academic medical centers to receive either standard-of-care (SOC) culture and AST or rapid organism identification and phenotypic AST using the Accelerate Pheno System (RAPID). All patients in both arms underwent prospective audit and feedback from antibiotic stewardship programs at the hospitals. The primary outcome was time to first antibiotic modification within 72 hours of randomization.

Among the 448 participants included in the final analysis, the mean time to organism identification was faster in the RAPID arm than in the SOC arm (2.7 hours vs 11.7 hours, P < 0.001), as was time to susceptibility results (13.5 hours vs 44.9 hours, P < 0.001). Median (interquartile range, [IQR]) hours to first antibiotic modification was faster in the RAPID vs SOC arm for overall antibiotics (8.6 hours vs 14.9 hours, difference 6.3 hours, P = 0.02) and for gram-negative antibiotics (17.3 hours vs 42.1 hours, difference 24.8, P < 0.001). Median (IQR) time to antibiotic escalation was also faster in the RAPID arm than the SOC arm for antibiotic-resistant BSIs (18.4 vs 61.7 hours, difference 43.3 hours, P = 0.01).

Analysis of patient outcomes found no statistically significant differences between the two arms for mortality, time to death, or length of hospital stay.

The authors of the National Institutes of Health–funded study say the results indicate that rapid ID and AST, implemented along with antibiotic stewardship measures, can help clinicians provide timely, effective therapy while also promoting more appropriate antibiotic use.

"Development of rapid, innovative methods for detection of microorganisms and drug resistance in blood cultures is an important component in the fight against antimicrobial resistance," they wrote.
May 6 Clin Infect Dis abstract

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